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Förlossningsbristningar involverar olika former av skador på vagina, vulva, perineum och analsfinktrar. Skadan kan uppstå spontant under födseln eller genom iatrogena skador som hälso- och sjukvården åstadkommit. Bristningar uppskattas drabba cirka 80 procent av förstföderskor och kan leda till komplikationer som kan påverka livskvaliteten på flera sätt. Genom historien har vårdandet av bäckenbottens vävnader studerats, men allteftersom barnafödseln förflyttades till sjukhus och förlossningsvården medikaliserades kan en stor del av förlossningskunskapen ha försvunnit. Födslorummet blev till ett vårdrum och förlossningssfären till ett kliniskt skeende. Detta kan i sin tur ha bidragit till att förlossningsbristningar kommit att normaliseras. Syftet var att kartlägga hur olika metoder kan förebygga uppkomsten av förlossningsbristningar. Vald metod blev en icke-systematisk litteraturöversikt som omfattade randomiserade kontrollerade studier, observationsstudier, tvärsnittsstudier samt kohortstudier med kvantitativ design. Databassökningen utfördes i PubMed och CINAHL. En kvalitetsgranskning utfördes på samtliga artiklar och endast ett urval som uppfyllde grundläggande kvalitetskrav ingick i litteraturöversikten. Med hjälp av en integrerad analys kunde en sammanvägning av flera studier genomföras och sammanställas till ett gemensamt resultat. Kvantitativa data extraherades från artiklarnas resultat och omformulerades till beskrivande text. Totalt 31 artiklar med kvantitativ ansats identifierades som svarade an på syftet och blev grunden för den icke-systematiska litteraturöversikten. Genom dataanalysen identifierades flera metoder som kan förebygga uppkomsten av förlossningsbristningar. Samtliga metoder delades in under två huvudkategorier: ”Metoder med god skyddande effekt på förlossningsbristningar” samt ”Metoder med tveksamt skyddande effekt på förlossningsbristningar”, med sju tillhörande underkategorier: ”Vårdande av perineum under graviditeten”, ”Vårdande av perineum i samband med förlossningen”, ”Barnmorskeledd förlossning”, ”Ett kontrollerat framfödande”, ”Barnmorskans händer och kommunikation som verktyg för att motverka förlossningsbristningar”, ”förlossningspositioner och att föda i vatten” samt ”Perineotomi i förebyggande syfte mot förlossningsbristningar”. Slutsatsen indikerade på flera metoder som kan motverka uppkomsten av förlossningsbristningar. De metoder som visade på god skyddande effekt var värme och perinealmassage, barnmorskeledda förlossningar och närvaron av två barnmorskor vid framfödandet samt att föda i sidoläge och fyrfota position. Metoder som visade på tveksamt skyddande effekt relaterat till tvetydiga resultat var att föda i litotomiläge, rutinmässig användning av perineotomi samt hands on-tekniken. På grund av osäker evidens ökar komplexiteten för forskningsområdet. / Vaginal tearing involves various forms of damage to the vagina, vulva, perineum and anal sphincters. Vaginal tearing can occur spontaneously during birth or through iatrogenic injuries achieved by the healthcare providers. Vaginal tearing is estimated to affect about 80 percent of primiparous women and can lead to complications that can affect the quality of life in several ways. Throughout history, care of the pelvic floor tissues has been studied, but as maternity care has become more medicalized, pregnancy and childbirth came to be seen as a pathological event. This, in turn, may have contributed towards the normalization of vaginal tearing. The aim was to examine how different methods can prevent the occurrence of vaginal tearing during childbirth. The method chosen was a scoping review that included the analysis of randomized controlled trials, observational studies, cross-sectional studies and cohort studies utilizing a quantitative approach. The database search was performed in PubMed and CINAHL. A quality review was performed on all articles and only the selection that met the quality requirements was included. By using an integrated analysis several studies compiled to produce a conclusive result. Quantitative data was extracted from the results of the articles and reformulated into a descriptive text. A total of 31 articles with a quantitative approach were identified that answered this thesis’ aim and built the structure of the scoping review. Through the data analysis, two main categories with associated sub-categories were identified. The main categories that have emerged are: "Methods with good protective effect on vaginal tearing" and "Methods with questionable protective effect on vaginal tearing". Sub-categories that have been identified are: "Perineal care during pregnancy", "Perineal care during birth”, "Midwife-led birth", “Controlled vaginal delivery”, "Midwife's hands and communication to prevent vaginal tearing”, "Delivery positions and water birth" and "Episiotomy as a preventive measure against vaginal tearing ". The conclusions of this thesis’ research indicated several methods that could prevent vaginal tearing. In particular, there was good evidence to establish that caring for the perineal area by massaging the perineum and applying warm compresses, midwife-led birth and the presence of two midwifes during birth as well as birth in lateral position and hands-and-knees position. Methods that were found to be ineffective included birth in litothomy position, routine practice of episiotomy as well as the hands on-technique. Due to inconclusive evidence the complexity of the research area increases.

High-fidelity computer simulations of childbirth are time consuming, making them impractical for guiding decision-making during obstetric emergencies. The complex geometry, micro-structure, and large finite deformations undergone by the vagina during childbirth result in material and geometric nonlinearities, complicated boundary conditions, and nonhomogeneities within finite element (FE) simulations. Such nonlinearities pose a significant challenge for numerical solvers, increasing the computational time. Simplifying assumptions can reduce the computational time significantly, but this usually comes at the expense of simulation accuracy. The work herein proposed the use of reduced order modeling (ROM) techniques to create surrogate models that capture experimentally-measured displacement fields of rat vaginal tissue during inflation testing in order to attain both the accuracy of higher-fidelity models and the speed of lower-fidelity simulations. The proper orthogonal decomposition (POD) method was used to extract the significant information from FE simulations generated by varying the luminal pressure and the parameters that introduce the anisotropy in the selected constitutive model. In our first study, a new data-driven (DD) variational multiscale (VMS) ROM framework was extended to obtain the displacement fields of rat vaginal tissue subjected to ramping luminal pressure. For comparison purposes, we also investigated the classical Galerkin ROM (G-ROM). In our numerical study, both the G-ROM and the DD-VMS-ROM decreased the FE computational cost by orders of magnitude without a significant decrease in numerical accuracy. Furthermore, the DD-VMS-ROM improved the G-ROM accuracy at a modest computational overhead. Our numerical investigation showed that ROM had the potential to provide efficient and accurate computational tools to describe vaginal deformations, with the ultimate goal of improving maternal health. Our second study compared two common computational strategies for surrogate modeling, physics-based G-ROM and data-driven machine learning (ML), for decreasing the cost of FE simulations of the ex vivo deformations of rat vaginal tissue subjected to inflation testing to study the effect of a pre-imposed tear. Since there are many methods associated with each modeling approach, to provide a fair and natural comparison, we selected a basic model from each category. From the ROM strategies, we considered a simplified G-ROM that is based on the linearization of the underlying nonlinear FE equations. From the ML strategies, we selected a feed-forward dense neural network (DNN) to create mappings from constitutive model parameters and luminal pressure values to either the FE displacement history (in which case we denote the resulting model ML) or the POD coefficients of the displacement history (in which case we denote the resulting model POD-ML). The numerical comparisons of G-ROM, ML, and POD-ML took place in the reconstructive regime. The numerical results showed that the G-ROM outperformed the ML model in terms of offline central processing unit (CPU) time for model training, online CPU time required to generate approximations, and relative error with respect to the FE models. The POD-ML model improved on the speed performance of the ML, having online CPU times comparable to those of the G-ROM given the same size of POD bases. However, the POD-ML model did not improve on the error performance of the ML. In our last study, we expanded our investigation of ML methods for surrogate modeling by comparing the performance of a DNN similar to what was used previously to that of a convolutional neural network (CNN) using 1-D convolution on the input parameters from FE simulations of active vaginal tearing. The new FE simulations utilized a custom continuum damage model that provided material damage and failure properties to an existing anisotropic hyperelastic constitutive model to replicate experimentally-observed tear propagation behaviors. We employed our DNN and CNN models to create mappings from constitutive model parameters, geometric properties of the propagating tear, and luminal pressure values to either the full FE displacement history or the POD coefficients of the displacement history. The root-mean-square error (RMSE) with respect to the FE displacement history achieved by full order output ML predictions was reproducible with POD-ML using a basis of only dimension l=10. Additionally, an order of magnitude reduction in offline time was observed using POD-ML over full-order ML with minimal difference between DNN and CNN architectures. Differences in online computational costs between ML and POD-ML were found to be negligible, but the DNNs produced predictions slightly faster than the CNNs, though both online times were on the same order of magnitude. While convolution did not significantly aid the regression task at hand, POD-ML was demonstrated to be an efficient and effective approach for surrogate modeling of the FE tear propagation model, approximating the displacement history with RMSE less than 0.1 mm and generating results 7 orders of magnitude faster than the FE model. This set of baseline numerical investigations serves as a starting point for future computer simulations that consider state-of-the-art G-ROM and ML strategies, and the in vivo geometry, boundary conditions, material properties, and tissue damage mechanics of the human vagina, as well as their changes during labor. / Doctor of Philosophy / Computer simulations of childbirth are extremely time-consuming, making them impractical for guiding decision-making by obstetricians when a patient is entering labor. The complex geometry, material microstructure, and large deformations undergone by the vagina during childbirth result in material and geometric properties that are challenging to mathematically model. Consequently, numerical solver methods (e.g., finite elements) require large amounts of time to simulate childbirth. Simplifying assumptions can reduce computational time, but this simplification usually comes at the expense of simulation accuracy. The work of this dissertation proposes the use of several techniques to reduce model complexity and create accurate approximations and predictions of results from full-order models (FOMs) with profound reductions in computational time. Our first study used reduced order models (ROMs) to extract the significant information from a FOM of the rat vagina subjected to inflation. We compared a basic ROM and an advanced, data-driven ROM. Our second study compared the basic ROM to a basic machine learning (ML) technique for approximating a FOM that simulated inflation of the rat vagina with a pre-imposed tear. A hybrid technique incorporating elements of both ROM and ML to approximate FOM results was also considered. Our final study made use of ML and hybrid techniques using a more advanced neural network (a convolutional neural network). These ML models were used to predict the results of a FOM simulation of vaginal tear propagation. These numerical investigations serve as a starting point for future development of computer simulations using state-of-the-art ROM and ML strategies as well as more realistic models for the mechanics of the human vagina during childbirth.

Tableau d’honneur de la Faculté des études supérieures et postdoctorales, 2009-2010 / OBJECTIF: La rupture utérine lors de l'accouchement constitue l'une des pires urgences obstétricales. Récemment, des études comportant de faibles tailles d'échantillon ont suggéré que la fermeture de l'utérus lors d'une première césarienne pouvait influencer le risque de rupture utérine lors d'un accouchement subséquent. Notre objectif est d'évaluer l'impact d'une fermeture en un plan comparativement à une fermeture en deux plans sur le risque de rupture utérine. MÉTHODOLOGIE: Une étude cas-témoins multicentrique a été réalisée parmi des femmes qui ont eu un essai de travail après une seule césarienne transversale basse antérieure. Nous avons évalué les facteurs associés aux cas de rupture utérine complète incluant: le type de fermeture, le matériel de suture, la raison de la césarienne antérieure, le diabète, un accouchement vaginal antérieur, le déclenchement du travail, la maturation cervicale, l'utilisation de prostaglandine, l'âge et le poids maternel, le poids à la naissance, l'âge gestationnel et l'intervalle entre les grossesses. Pour chacun des cas, trois femmes du même centre hospitalier ayant eu un essai de travail sans rupture utérine ont été sélectionnées Les cas de rupture utérine avec une issue néonatale défavorable (pH<7.0 et/ou Apgar à 5 min <4) ont été analysés séparément dans un deuxième temps. Une régression logistique multivariée incluant les facteurs significatifs dans les analyses uni variées a été complétée. Les résultats ont été rapportés sous forme de ratio de cotes nonajustés et ajustés pour les variables confondantes avec un intervalle de confiance de 95%. RÉSUL TATS: Quatre-vingt-seize cas de ruptures utérines incluant 28 cas avec des issues néonatales défavorables et 288 témoins ont été inclus. Dans les analyses univariées, la fermeture en un plan, un intervalle entre les grossesses <24 mois, un déclenchement du travail avec un col non favorable, l'utilisation d'oxytocine et un poids à la naissance ~ 3500 grammes ont été associés à un risque accru de rupture utérine, contrairement à l'accouchement vaginal antérieur qui avait un effet protecteur. Après ajustement pour les variables confondantes, seule la fermeture en un plan (RC : 2.22,95 % IC: 1.23-4.01) et un . poids à la naissance ~ 3500 grammes (RC: 2.0~, 95 % IC: 1.22-3.30) sont demeurés associés à un risque accru de rupture utérine, alors que l'accouchement vaginal antérieur conservait son effet protecteur (RC : 0.49, 95 % IC: 0.25-0.95). Le seul facteur significatif associé à la rupture utérine avec issue néonatale défavorable était la fermeture en un seul plan (RC : 2.92, 95% IC 1.02-8.33). CONCLUSION: La fermeture en un plan est associée à un risque accru de rupture utérine comparativement à la fermeture en deux plans. La fermeture en un plan devrait donc être évitée chez les femmes qui envisagent un accouchement vaginal après une césarienne lors d'une future grossesse.

INTRODUÇÃO: A Bexiga Hiperativa é uma síndrome de alta prevalência que acomete negativamente a qualidade de vida das mulheres. Os sintomas clínicos se manifestam por urgência miccional, com ou sem incontinência de urgência, frequência e nocturia. O diagnóstico é definido a partir dos sintomas clínicos, sendo o diário miccional um bom instrumento de avaliação. O tratamento fisioterapêutico da bexiga hiperativa tem como opções a eletroestimulação transcutânea do nervo tibial ou eletroestimulação vaginal. OBJETIVO: verificar se a adição da eletroestimulação vaginal à eletroestimulação transcutânea do nervo tibial é mais eficaz do que somente a eletroestimulação no nervo tibial para o tratamento de mulheres com bexiga hiperativa. MÉTODO: Estudo controlado aleatorizado com 106 mulheres, maiores de 18 anos, com diagnóstico de bexiga hiperativa ou incontinência urinária mista com predomínio dos sintomas de bexiga hiperativa. As pacientes foram distribuídas em dois grupos: Grupo 1: eletroestimulação transcutânea do nervo tibial (n=52) e Grupo 2: eletroestimulação vaginal mais eletroestimulação transcutânea do nervo tibial (n=54). Ambos os grupos foram orientados quanto à terapia comportamental. Os instrumentos de avaliação utilizados foram: Diário Miccional de três dias, avaliação funcional do assoalho pélvico, King´s Health Questionnaire e Overactive Bladder Questionnaire, todos aplicados por um avaliador cego, antes e após o tratamento que teve duração de 12 semanas, 1x/semana. O desfecho primário foi a frequência urinária em 24 horas. Os desfechos secundários foram os outros sintomas da bexiga hiperativa, o impacto na qualidade de vida e a funcionalidade do assoalho pélvico. RESULTADO: a frequência urinária no grupo 2 diminuiu em 1,5 vezes em relação ao grupo 1. Contudo este resultado não foi clinicamente relevante pois foi inferior a 3 micções. As outras variáveis do diário miccional bem como como o impacto na qualidade de vida, não apresentaram diferenças entre os grupos. CONCLUSÃO: a adição da eletroestimulação vaginal à eletroestimulação transcutânea do nervo tibial não apresentou resultados mais efetivos na melhora dos sintomas ou na qualidade de vida das pacientes com BH / INTRODUCTION: Overactive Bladder is a syndrome with a high prevalence that negatively affects women\'s quality of life. The clinical symptoms are manifested as urinary urgency, with or without urgency incontinence, frequency and nocturia. The diagnosis is defined based on the clinical symptoms, and the voiding diary is a good assessment. The physiotherapeutic treatment of OAB has as treatment\'s options the transcutaneous tibial nerve electrical stimulation or vaginal electrical stimulation. OBJECTIVE: to verify if the addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation is more effective than only the electrical stimulation in the tibial nerve for the treatment of women with OAB. METHOD: Randomized controlled trial with 106 women over 18 years old with a diagnosis of overactive bladder or mixed urinary incontinence with predominance of overactive bladder symptoms. The patients were distributed into two groups: Group 1: transcutaneous tibial nerve electrical stimulation (n = 52) and Group 2: vaginal electrical stimulation plus transcutaneous tibial nerve electrical stimulation (n = 54). Both groups received instructions about behavioral therapy. The assessments used were: Three-day voiding diary, functional evaluation of pelvic floor, King\'s Health Questionnaire and Overactive Bladder Questionnaire, all of them applied by a blind evaluator, before and after 12-week treatment, once a week. The primary outcome was urinary frequency in 24 hours. Secondaries outcomes were other overactive bladder symptoms, impact in quality of life, and pelvic floor functionality. RESULTS: urinary frequency in group 2 decreased 1.5 times in relation to group 1. However, this result was not clinically relevant since it was less than 3 mictions. The other variables of voiding diary and impact on quality of life did not present differences between groups. CONCLUSION: The addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation did not present more effective results in the improvement of symptoms or quality of life in patients with overactive bladder

Made available in DSpace on 2016-07-27T14:20:53Z (GMT). No. of bitstreams: 1 Tayssa Andrade Batista Novato Machado.pdf: 1002749 bytes, checksum: fcfda75cce20c8e392a6858cdf2c5c06 (MD5) Previous issue date: 2015-08-31 / The present study aimed at modifying difficult (awkward) actions related to sexual behavior, such as comments related to dissatisfaction with the partner and the use of artificial lubricants, through general and specific behavioral interventions. With respect to general behavioral interventions we applied several techniques, like instruct through information, provide feedback, prioritize tasks, and provide models and instructions as positive reinforcement, while with specific behaviors we included teaching discriminative training of bodily responses before and during sexual intercourse. In addition, as a case study, it aimed to evaluate the antecedents and consequences of sexual dysfunction reported by a participant female of 26 years with a stable partner. The functional evaluation included procedures through an interview and a questionnaire. Further, we also used behavioral logging activity (self-monitoring). To demonstrate that interventions (independent variable) had effect on the dependent variable we used the design of alternating-type treatments (ABC) succeed by follow-up. The results showed decrease in behaviors-problem and increase of skilled actions related to sexual behavior, such as reports of satisfaction with the partner and vaginal lubrication response. / O presente estudo objetivou a modificação de ações inábeis relacionadas ao comportamento sexual, bem como dos relatos de insatisfação com o parceiro e do uso de lubrificantes artificiais, por meio de intervenções comportamentais gerais (instruir por meio de informações, fornecer feedbacks, hierarquizar tarefas, fornecer modelos e instruções e instruir o uso do reforçamento positivo) e específicas (ensinar o treino discriminativo das respostas corporais antes do coito e ensinar o treino discriminativo das respostas corporais durante o coito). Ainda objetivou avaliar os antecedentes e consequentes da disfunção sexual relatada por uma participante do sexo feminino, de 26 anos e com parceiro fixo. A avaliação funcional incluiu procedimentos indiretos por meio de uma entrevista e de um questionário. Também utilizou-se de uma atividade de registro comportamental (auto-observação). Para demonstração de que as intervenções (variável independente) é que produziram efeito sobre a variável dependente, foi empregado o delineamento de tratamentos alternados do tipo (ABC) seguido por follow-up. Os resultados demonstraram diminuição dos comportamentosproblema e aumento de ações hábeis relacionadas ao comportamento sexual, de relatos de satisfação com o parceiro e da resposta de lubrificação vaginal.

INTRODUÇÃO: A Bexiga Hiperativa é uma síndrome de alta prevalência que acomete negativamente a qualidade de vida das mulheres. Os sintomas clínicos se manifestam por urgência miccional, com ou sem incontinência de urgência, frequência e nocturia. O diagnóstico é definido a partir dos sintomas clínicos, sendo o diário miccional um bom instrumento de avaliação. O tratamento fisioterapêutico da bexiga hiperativa tem como opções a eletroestimulação transcutânea do nervo tibial ou eletroestimulação vaginal. OBJETIVO: verificar se a adição da eletroestimulação vaginal à eletroestimulação transcutânea do nervo tibial é mais eficaz do que somente a eletroestimulação no nervo tibial para o tratamento de mulheres com bexiga hiperativa. MÉTODO: Estudo controlado aleatorizado com 106 mulheres, maiores de 18 anos, com diagnóstico de bexiga hiperativa ou incontinência urinária mista com predomínio dos sintomas de bexiga hiperativa. As pacientes foram distribuídas em dois grupos: Grupo 1: eletroestimulação transcutânea do nervo tibial (n=52) e Grupo 2: eletroestimulação vaginal mais eletroestimulação transcutânea do nervo tibial (n=54). Ambos os grupos foram orientados quanto à terapia comportamental. Os instrumentos de avaliação utilizados foram: Diário Miccional de três dias, avaliação funcional do assoalho pélvico, King´s Health Questionnaire e Overactive Bladder Questionnaire, todos aplicados por um avaliador cego, antes e após o tratamento que teve duração de 12 semanas, 1x/semana. O desfecho primário foi a frequência urinária em 24 horas. Os desfechos secundários foram os outros sintomas da bexiga hiperativa, o impacto na qualidade de vida e a funcionalidade do assoalho pélvico. RESULTADO: a frequência urinária no grupo 2 diminuiu em 1,5 vezes em relação ao grupo 1. Contudo este resultado não foi clinicamente relevante pois foi inferior a 3 micções. As outras variáveis do diário miccional bem como como o impacto na qualidade de vida, não apresentaram diferenças entre os grupos. CONCLUSÃO: a adição da eletroestimulação vaginal à eletroestimulação transcutânea do nervo tibial não apresentou resultados mais efetivos na melhora dos sintomas ou na qualidade de vida das pacientes com BH / INTRODUCTION: Overactive Bladder is a syndrome with a high prevalence that negatively affects women\'s quality of life. The clinical symptoms are manifested as urinary urgency, with or without urgency incontinence, frequency and nocturia. The diagnosis is defined based on the clinical symptoms, and the voiding diary is a good assessment. The physiotherapeutic treatment of OAB has as treatment\'s options the transcutaneous tibial nerve electrical stimulation or vaginal electrical stimulation. OBJECTIVE: to verify if the addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation is more effective than only the electrical stimulation in the tibial nerve for the treatment of women with OAB. METHOD: Randomized controlled trial with 106 women over 18 years old with a diagnosis of overactive bladder or mixed urinary incontinence with predominance of overactive bladder symptoms. The patients were distributed into two groups: Group 1: transcutaneous tibial nerve electrical stimulation (n = 52) and Group 2: vaginal electrical stimulation plus transcutaneous tibial nerve electrical stimulation (n = 54). Both groups received instructions about behavioral therapy. The assessments used were: Three-day voiding diary, functional evaluation of pelvic floor, King\'s Health Questionnaire and Overactive Bladder Questionnaire, all of them applied by a blind evaluator, before and after 12-week treatment, once a week. The primary outcome was urinary frequency in 24 hours. Secondaries outcomes were other overactive bladder symptoms, impact in quality of life, and pelvic floor functionality. RESULTS: urinary frequency in group 2 decreased 1.5 times in relation to group 1. However, this result was not clinically relevant since it was less than 3 mictions. The other variables of voiding diary and impact on quality of life did not present differences between groups. CONCLUSION: The addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation did not present more effective results in the improvement of symptoms or quality of life in patients with overactive bladder

Yuan, Qin. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 112-119). / Abstracts in English and Chinese. / Acknowledgements --- p.III / Publications --- p.V / List of Abbreviations --- p.VI / List of Figures --- p.VII / List of Tables --- p.VIII / Abstract in English --- p.IX / Abstract in Chinese --- p.XII / Table of Contents --- p.XIII / Chapter CHAPTER1 I --- NTRODUCTION --- p.1 / Chapter 1.1 --- What is telemedicine --- p.1 / Chapter 1.2 --- What is telepathology --- p.4 / Chapter 1.2.1 --- Types of telepathology system --- p.7 / Chapter 1.2.2 --- Main events in the development of telepathology --- p.9 / Chapter 1.2.3 --- Diagnostic accuracy in telepathology and telecytology --- p.12 / Chapter 1.2.4 --- Applications of telepathology --- p.18 / Chapter 1.2.4.a --- Remote primary diagnosis --- p.18 / Chapter 1.2.4.b --- Remote expert consultation --- p.19 / Chapter 1.2.4.c --- "Image libraries, databases and archiving" --- p.20 / Chapter 1.2.4.d --- Quality assurance --- p.20 / Chapter 1.2.4.e --- Remote teaching and training --- p.21 / Chapter 1.3 --- Technical aspects of telepathology --- p.24 / Chapter 1.3.1 --- Image presentation --- p.24 / Chapter 1.3.2 --- Image acquisition and display --- p.25 / Chapter 1.3.3 --- Image compression --- p.27 / Chapter 1.3.4 --- Networking and line connections --- p.29 / Chapter 1.3.4.a --- Public (analog) telephone network --- p.29 / Chapter 1.3.4.b --- Integrated services digital network (ISDN) --- p.30 / Chapter 1.3.4.c --- Computer network --- p.30 / Chapter 1.3.4.d --- Asynchronous transfer mode (ATM) --- p.31 / Chapter 1.4 --- Legal and ethical aspects --- p.32 / Chapter 1.4.1 --- Licensure of the facility --- p.33 / Chapter 1.4.2 --- Licensure of the pathologist --- p.33 / Chapter 1.4.3 --- Accreditation --- p.34 / Chapter 1.4.4 --- The electronic medical record: privacy --- p.35 / Chapter 1.4.5 --- Malpractice liability --- p.36 / Chapter 1.4.6 --- Reimbursement --- p.38 / Chapter 1.4.7 --- Conclusion --- p.38 / Chapter 1.5 --- Telemedicine and telepathology in China --- p.40 / Chapter 1.6 --- Cytopathology practice in China --- p.42 / Chapter CHAPTER2 --- OBJECTIVES OF STUDY --- p.46 / Chapter CHAPTER3 --- MATERIALS AND METHODS --- p.48 / Chapter 3.1 --- Case materials --- p.48 / Chapter 3.2 --- Static image capture and display --- p.51 / Chapter 3.3 --- Static telecytology study --- p.55 / Chapter 3.4 --- Web-based tutorial program --- p.59 / Chapter 3.4.1 --- Pre-tutorial evaluation --- p.60 / Chapter 3.4.2 --- Cytology tutorial --- p.62 / Chapter 3.4.3 --- Post-tutorial evaluation --- p.66 / Chapter 3.4.4 --- Data analysis --- p.67 / Chapter 3.5 --- Dynamic telecytology study --- p.68 / Chapter 3.5.1 --- Equipment --- p.68 / Chapter 3.5.2 --- Trial design --- p.72 / Chapter 3.5.2a --- Telecytology diagnosis --- p.72 / Chapter 3.5.2b --- Light microscopy diagnosis --- p.73 / Chapter 3.5.2c --- Data analysis --- p.74 / Chapter CHAPTER4 --- RESULTS --- p.75 / Chapter 4.1 --- General information about participating cytology laboratories --- p.75 / Chapter 4.2 --- Static telecytology study --- p.78 / Chapter 4.2.1 --- Telecytology diagnostic agreement --- p.78 / Chapter 4.2.2 --- Confidence of telecytology diagnosis --- p.80 / Chapter 4.2.3 --- "The acceptance of the image quality, time required for each case" --- p.83 / Chapter 4.3 --- Web-based program on cervical cytology --- p.84 / Chapter 4.4 --- Dynamic telecytology study --- p.86 / Chapter 4.4.1 --- Diagnostic accuracy --- p.86 / Chapter 4.4.2 --- Time studies --- p.88 / Chapter 4.4.3 --- Diagnostic certainty --- p.89 / Chapter 4.4.4 --- Image quality --- p.91 / Chapter CHAPTER5 --- DISCUSSION --- p.92 / Chapter 5.1 --- Static image telecytology study linking 14 Mainland China hospitals --- p.93 / Chapter 5.2 --- Problems encountered in setting up links with Mainland China --- p.97 / Chapter 5.3 --- Web-based tutorial programme for remote teaching --- p.100 / Chapter 5.4 --- Dynamic image telecytology study for immediate diagnosis at a distance --- p.103 / Chapter 5.5 --- Limitations of this study --- p.105 / Chapter 5.6 --- Concluding remarks --- p.108 / REFERENCES --- p.112

Made available in DSpace on 2015-07-22T20:49:36Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-10-28 / Em 2002, o Estado de Mato Grosso aderiu à segunda fase de intensificação Programa Nacional de Controle do Câncer do Colo do Útero (PNCCU) como medida de enfrentamento das altas taxas da doença e de morte por neoplasia cervical. Com o objetivo de analisar os principais resultados do PNCCU, foi feito um estudo em duas partes. A primeira parte teve como objetivo levantar o perfil da doença e a cobertura do exame rastreamento pelo PNCCU no Estado. Os objetivos da segunda parte foram: analisar o seguimento clínico da população rastreada, analisar as diferentes características evolutivas da doença associadas aos fatores sócio-demográficos e clínicos, bem como analisar o risco de óbito e a taxa de sobrevida estratificada pelas variáveis sócio-demográficas e clínicas das mulheres que apresentaram carcinoma invasivo. Na primeira parte, foi utilizado estudo do tipo transversal e na segunda parte, foi realizado um estudo de coorte. O período do estudo compreendeu de 2002 a 2007 e abrangeu todos os municípios do Estado de Mato Grosso. A população estudada na primeira fase do estudo correspondeu todas as mulheres que fizeram o exame de rastreamento no ano de 2002. Na segunda parte do estudo, a população correspondeu a uma amostra aleatória representativa das mulheres que apresentaram alterações citológicas na primeira fase do estudo, totalizando 323 mulheres. A fonte de dados utilizada foi o sistema de informação oficial de saúde, dentre eles o SISCOLO, SIM, APAC, além de dados oficiais da Secretaria Estadual de Saúde/MT (SES/MT), dados disponíveis no site do INCA e do DATASUS e prontuários clínicos. Para análise estatística dos dados foram utilizadas técnicas descritivas e inferenciais. Na parte descritiva foram utilizados tabelas, gráficos e medidas de posição e de dispersão. Para avaliar a o risco de adoecer por carcinoma cervical invasor foi utilizado regressão logística univariada e multivariada. Para analisar a taxa de sobrevida global foi utilizado o estimador de Kaplan-Meier e para analisar os fatores prognósticos, foi utilizado o modelo de riscos proporcionais de Cox. Dentre os principais resultados, destaca-se que no período estudado, Mato Grosso apresentou taxas de incidência elevadas, acima da média nacional. Os dados do seguimento clínico mostraram os diferentes desfechos, dentre eles, destaca-se que: entre as 323 mulheres, 18 (6,2%) foram a óbito tendo o câncer do colo do útero como causa básica da morte. Foi analisado o risco de a doença evoluir para o carcinoma invasor, segundo as variáveis sócio-demográficas e clínicas, sendo que as variáveis: faixa etária, estado civil, tabagismo, menarca e município foram as que apresentaram forte associação com a doença na fase invasora. Já na análise de sobrevivência, a taxa de sobrevida global em 60 meses, estimada pelo método de Kaplan-Meier, foi de 66,7%. No modelo final de risco proporcional de Cox, as variáveis com maior risco de óbito foi o estágio avançado da doença e a raça/cor. Estes dados levam a concluir que a doença no Estado de Mato Grosso tem uma determinação social muito grande, considerando a dificuldade de acesso aos serviços de saúde da população desfavorecida pelas condições raciais, sócio-econômicas, e chegam aos serviços com a doença em fase adiantada, quando a chance de sobrevivência é muito pequena. Conclui-se que para o efetivo combate a doença são necessárias políticas governamentais, como o PNCCU, que garantam a universalidade da assistência, principalmente da população desfavorecida socialmente. / In 2002, the State joined the second phase of intensification of the National Program for the Control of Cervical Cancer (PNCCU) as a measure to deal with the high rates of the disease and of death by cervical neoplasia. With the aim of analyzing the main PNCCU results, a two-stage study was carried out. The first phase aimed at presenting the disease profile and the coverage of the screening exam by the PNCCU in the State. The aims of the second phase were to analyze the clinical follow-up of the population that was screened, analyze the different evolutionary characteristics of the disease associated to socio-demographic and clinic factors, as well as analyze the factors associated to death risk and the stratified survival rate by the socio-demographic and clinical variables of women that presented invasive carcinoma. In the first part, the cross-sectional study was used and a cohort study was used in the second phase. The period of study was from 2002 to 2007 and comprised all the municipalities of the State of Mato Grosso. The population studied in the first phase of the study was all the women who had undergone the screening test in 2002. The population used in the second phase of the study was a representative random sample of those that presented cytological alterations in the first phase of the study, a total of 323 women. The source of data used was the official health information system, among them the SISCOLO, SIM, APAC, and also the official data of the State Health Department/MT (SES/MT), data available in the INCA and DATASUS sites and medical records. For the statistical analysis of the data, descriptive and inferential techniques were used. In the descriptive part, tables, graphics and position and dispersion measures were used. In order to evaluate the risk of being sick due to invasive cervical carcinoma, the univariate and multivariate logistic regression analysis was used. The Kaplan-Meier estimator was used to analyze the survival rate and to analyze the prognostic factors, the Cox proportional hazards model was used. Among the main results it is highlighted that in 2002, Mato Grosso presented high incidence rates, above the national average. The data of the clinical follow up showed the different clinical outcomes, among the 323 women, 18 (6,2%) died having as the basic cause of death the cervical cancer. The risk of the disease developing into the invasive carcinoma was analyzed according to the socio-demographic and clinical variables, and the variables: age group, marital status, smoking history, menopause and municipality were those that presented a strong association with the disease in the invasive phase. However, in the survival analysis, the global survival rate in 60 months, estimated by the Kaplan-Meier method, was of 66,7%. In the final Cox proportional hazards model, the variables with higher death risk was the advanced stage of the disease and the race/color. These data lead to a conclusion that the disease in the State of Mato Grosso has a very large social determination, considering the difficulties in the access to the health services by the population affected by racial, socio-economic conditions that arrive in the health services with the disease in an advanced stage, when the survival probability is very small. The conclusion is that for the effective fight against the disease governmental policies such as the PNCCU are necessary, and that the universality of the assistance be guaranteed, mainly to the socially disadvantaged population. / TEDE / BV UNIFESP: Teses e dissertações

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / O exame de Papanicolaou tem reconhecimento mundial enquanto estratÃgia segura para detectar o cÃncer de colo uterino precocemente. Envolve trabalho manual, da coleta do material atà a emissÃo do resultado. Portanto, o desempenho dos recursos humanos contribui para a seguranÃa ou nÃo dos resultados. Este exame à realizado por mÃdicos e enfermeiros que compÃem as equipes do Programa SaÃde da FamÃlia (PSF), todavia, predominantemente, pelos enfermeiros. Neste contexto, decidiu-se pela realizaÃÃo deste estudo que teve por objetivo geral avaliar a coleta de material para o exame de Papanicolaou por enfermeiras e como objetivos especÃficos verificar o conhecimento e a prÃtica dessas profissionais com relaÃÃo à coleta citolÃgica; identificar a disponibilidade dos recursos materiais necessÃrios à realizaÃÃo da coleta e avaliar adequabilidade do material coletado baseado no laudo laboratorial. Trata-se de um pesquisa avaliativa, com carÃter exploratÃrio-descritivo. Realizou-se em unidades do Programa SaÃde da FamÃlia (PSF) de Maranguape-CE, cujos dados foram coletados de agosto a outubro de 2006 por observaÃÃo estruturada direta e participativa junto Ãs 21 (100%) enfermeiras, em seus sÃtios de atuaÃÃo, e atravÃs da revisÃo dos laudos laboratoriais de 63 lÃminas coletadas. A observaÃÃo estruturada seguiu o Instrumento de Reconhecimento da Qualidade da Metodologia Proquali, sendo os dados anotados mediante sistema de checagem. Dados da observaÃÃo participativa foram registrados em diÃrio de campo. Os resultados foram apresentados nos itens: caracterizaÃÃo das enfermeiras; formaÃÃo, acesso a manuais tÃcnicos e conhecimentos para lidar com a coleta citolÃgica; desempenho das enfermeiras na coleta de material para o exame (medidas de biosseguranÃa, conforto e seguranÃa das mulheres durante exame e tÃcnica de coleta); disponibilidade de recursos para a realizaÃÃo do procedimento; e adequabilidade das lÃminas. A maioria das enfermeiras tinha entre nove e 11 anos de formadas. Dezessete (81%) se auto-avaliaram seguras para realizar o procedimento e 16 (76%) demonstraram ter conhecimento adequado sobre o local da coleta citolÃgica. O acesso à prÃtica de coleta citolÃgica na GraduaÃÃo foi referida por somente 7 (33%) das enfermeiras. Apenas 4 (19%) lavaram as mÃos antes do procedimento, 21 (100%) utilizaram luvas de procedimento nas duas mÃos e o descarte do lixo mostrou-se inadequado em todas as unidades. O conforto da usuÃria avaliado sob o ponto de vista de certificar-se se a mulher havia esvaziado a bexiga antes do exame e explicÃ-lo para usuÃria foi atendido por 2 (9,5%) e 4 (19%) das enfermeiras, respectivamente. A privacidade, avaliada pelos critÃrios de cobrir a mulher, manter a porta do consultÃrio fechada e impedir o âentra e saiâ de pessoas durante o exame foi alcanÃado por 20 (95%), 17 (81%) e 14 (67%), respectivamente. A tÃcnica da coleta foi satisfatÃria entre 90,5% ou mais dos enfermeiros em sete dos 11 itens avaliados e a adequabilidade das lÃminas mostrou-se satisfatÃria em 100% dos 63 laudos. O desempenho das enfermeiras foi o ideal esperado em termos de garantir lÃminas de qualidade ao rastreamento do cÃncer de colo, todavia, lavagem das mÃos, descarte adequado do lixo, conforto e seguranÃa da usuÃria e entrevista sobre condiÃÃes da mulher para a realizaÃÃo da coleta precisam melhorar. Risco de dessecamento, presenÃa de sangue e material hipocelular foram observados, porÃm nÃo geraram lÃminas insatisfatÃrias, sobre o que se sugere que estudos sejam realizados com o objetivo de avaliar recomendaÃÃes desnecessÃrias ou excessivas à coleta. / The Pap test has world-wide recognition as a safe strategy to detect cervical cancer early. Its execution includes manual work, from the material collection to the result emission. Thus, the performance of human resources contributes to the security or not of the results. This is carried out by doctors and nurses that compose the teams of Health Family Program (PSF), but mainly by nurses. In this context, it was decided to carry out this study which had as a general objective to evaluate the material collection for the Pap test by nurses and as specific objectives to verify knowledge and practice of these professionals in relation to cytological collection; to identify the availability of material resources which are necessary for the execution of the collection and to evaluate if the collected material is adequate based on the laboratorial report. It is an evaluative research, with descriptive exploratory character. It was executed in units of the Family Health Program (PSF) in Maranguape-CE, whose data was collected from August to October, 2006, through the direct and participative structured observation made with 21 (100%) nurses, in their area, and through the review of the laboratorial reports of 63 collected slides. The structured observation followed the Instrument of Quality Recognition of Proquali Methodology, and the data was annotated using checking system. The participative observation data was registered in field books. The results were presented under nurse characterization; formation, access to technical handbooks and knowledge to deal with cytological collection; performance of nurses in the material collection for the exam (biosecurity measures, comfort and security of women during exam and collection technique); availability of resources for the execution of the procedure and; suitability of the slides. Most nurses were graduated for 9 to 11 years and had 8 years of experience with cytological collection. Seventeen (81%) evaluated themselves as secure to execute the procedure and sixteen (76%) showed to have the adequate knowledge about the exact localization of the cytological collection. The access to the practice of cytological collection at college was referred by only 7 (33%) of them. Only 4 (19%) washed the hands before the procedure, 21 (100%) used procedure gloves in both hands and the discard of the trash was inadequate in all the units. Usersâ comfort was evaluated according to the standpoint of making sure if the woman had emptied the bladder before the exam and of explaining it to the user and was achieved by 2 (9,5%) and 4 (19%) of the nurses respectively. The privacy was evaluated by the criteria of covering the woman, maintaining the officeâs door closed and preventing peopleâs getting in and out during the exam. It was achieved by 20 (95%), 17 (81%) and 14 (67%), respectively. The collection technique was satisfactory with 90,5% or more of the nursed in 7 of the 11 evaluated items and the suitability of blenders was satisfactory in 100% of the 63 reports. The nursesâ performance was the ideal expected in terms of guaranteeing slides with good quality to search cervical cancer. However, practice at college, washing of hands, adequate discard of the trash, usersâ comfort and security and the interview about womenâs conditions for the execution of the collection need improvement. It was observed risk of desiccation, presence of blood and hypocelular material, but unsatisfactory slides were not generated. It is suggested that studies need to be carried out with the objective of evaluating unnecessary or excessive recommendations for the collection.